Skin complications other than pressure ulcers following spinal cord injury

Spinal Cord Injury Suppresses Cutaneous Inflammation: Implications for Peripheral Wound Healing

People who suffer a traumatic spinal cord injury (SCI) are at increased risk for developing dermatological complications. These conditions increase cost of care, incidence of rehospitalization, and the risk for developing other infections. The consequences of dermatological complications after SCI are likely exacerbated further by post-injury deficits in neural-immune signaling. Indeed, a functional immune system is essential for optimal host defense and tissue repair. Here, we tested the hypothesis that SCI at high spinal levels, which causes systemic immune suppression, would suppress cutaneous inflammation below the level of injury. C57BL/6 mice received an SCI (T3 spinal level) or sham injury; then one day later complete Freund's adjuvant (CFA) was injected subcutaneously below the injury level. Inflammation was quantified by injecting mice with V-Sense, a perfluorocarbon (PFC) tracer that selectively labels macrophages, followed by in vivo imaging. The total radiant efficiency, which is proportional to the number of macrophages, was measured over a 4-day period at the site of CFA injection. Fluorescent in vivo imaging revealed that throughout the analysis period, the macrophage reaction in SCI mice was reduced ∼50% compared with sham-injured mice. Radiant efficiency data were confirmed using magnetic resonance imaging (MRI), and together the data indicate that SCI significantly impairs subcutaneous inflammation. Future studies should determine whether enhancing local inflammation or boosting systemic immune function can improve the rate or efficiency of cutaneous wound healing in individuals with SCI. Doing so also could limit wound infections or secondary complications of impaired healing after SCI.

Prevention Practice Differences Among Persons With Spinal Cord Injuries Who Rarely Versus Frequently Sustain Pressure Ulcers

Pressure ulcers are common among people with spinal cord injury (SCI) and not only are costly to treat but also affect the quality of life of those affected by them. Despite a plethora of literature on prevention, there are few wellness studies focusing on the practices of people who do not develop pressure ulcers. This preliminary study sought to compare persons with spinal cord injury with consistent healthy skin histories to those with chronic pressure ulcer problems, focusing on behavioral habits of self-care. Data from 86 individuals 6 to 17 years postinjury were gathered by a mail and telephone survey investigating demographics and behavioral management lifestyle practices and factors attributed to success in preventing ulcers. Chi-square and follow-up analyses of variance indicated the group practices of those relatively ulcer free, who were female, were employed, weighed less, performed frequent pressure releases, experienced fewer ulcers during the first year, were less likely to smoke, consumed less alcohol, had fewer incontinence or moisture problems, had more sensation in the buttocks region, and were more physically active. Relevance to rehabilitation counselors in working with this population and addressing this debilitating problem is explored.

Some Problems of the Lower Extremity in Patients with Spinal Cord Injuries

Spinal cord injury (SCI) is devastating, leaving patients wholly or partly paralyzed. Health care providers who care for SCI patients during the acute or chronic phases are faced with different phenomena in the lower extremities of these subjects. In this article, the authors review the relevant changes associated with SCI. Preventive measures of these medical complications are directed according to the specific cause. Early comprehensive rehabilitation carried out by a specialized team prevents complications while enhancing functional gains.

Injuries to appendage extremities and digit tips: A clinical and cellular update

BACKGROUND

The regrowth of amputated appendage extremities and the distal tips of digits represent models of tissue regeneration in multiple vertebrate taxa. In humans, digit tip injuries, including traumatic amputation and crush injuries, are among the most common type of injury to the human hand. Despite clinical reports demonstrating natural regeneration of appendages in lower vertebrates and human digits, current treatment options are suboptimal, and are complicated by the anatomical complexities and functions of the different tissues within the digits.

RESULTS

In light of these challenges, we focus on recent advancements in understanding appendage regeneration from model organisms. We pay special attention to the cellular programs underlying appendage regeneration, where cumulative data from salamanders, fish, frogs, and mice indicate that regeneration occurs by the actions of lineage-restricted precursors. We focus on pathologic states and the interdependency that exists, in both humans and animal models, between the nail organ and the peripheral nerves for successful regeneration.

CONCLUSIONS

The increased understanding of regeneration in animal models may open new opportunities for basic and translational research aimed at understanding the mechanisms that support limb regeneration, as well as amelioration of limb abnormalities and pathologies.

Do you have the nerves to regenerate? The importance of neural signalling in the regeneration process

The importance of nerve-derived signalling for correct regeneration has been the topic of research for more than a hundred years, but we are just beginning to identify the underlying molecular pathways of this process. Within the current review, we attempt to provide an extensive overview of the neural influences during early and late phases of both vertebrate and invertebrate regeneration. In general, denervation impairs limb regeneration, but the presence of nerves is not essential for the regeneration of aneurogenic extremities. This observation led to the "neurotrophic factor(s) hypothesis", which states that certain trophic factors produced by the nerves are necessary for proper regeneration. Possible neuron-derived factors which regulate regeneration as well as the denervation-affected processes are discussed.

Dermatological problems following spinal cord injury in Korean patients

OBJECTIVE

To identify dermatological conditions following spinal cord injury (SCI) and analyze these conditions in relation to various characteristics of SCI.

DESIGN

Retrospective chart review.

SETTING

National Health Insurance Corporation Ilsan Hospital of Korea, Rehabilitation Center, Spinal Cord Unit.

PARTICIPANTS

Patients treated for SCI who were referred to dermatology for dermatological problems, 2000-2012.

RESULTS

Of the 1408 SCI patients treated at the spinal cord unit, 253 patients with SCI were identified to have been referred to dermatology for skin problems and a total of 335 dermatological conditions were diagnosed. The most common dermatological finding was infectious (n = 123, 36.7%) followed by eczematous lesions (n = 109, 32.5%). Among the infectious lesions, fungal infection (n = 76, 61.8%) was the most common, followed by bacterial (n = 27, 21.9%) lesions. Seborrheic dermatitis (n = 59, 64.1%) was the most frequent eczematous lesion. Ingrown toenail occurred more frequently in tetraplegics whereas vascular skin lesions occurred more commonly in patients with paraplegia (P < 0.05). Xerotic dermatitis showed a higher occurrence within 12 months of injury rather than thereafter (P < 0.05). Of these, 72.4% of the infectious and 94.7% of the fungal skin lesions manifested below the neurological level of injury (NLI; P < 0.001) and 61.5% of the eczematous lesions and 94.9% of seborrheic dermatitis cases occurred above the NLI (P < 0.001). There was no significant difference in dermatological diagnoses between patients with neurologically complete and incomplete SCI.

CONCLUSION

The most common dermatological condition in patients with SCI among those referred to dermatology was fungal infection, followed by seborrheic dermatitis. Although dermatological problems after SCI are not critical in SCI outcome, they negatively affect the quality of life. Patients and caregivers should be educated about appropriate skin care and routine dermatological examinations.

Clonal analysis reveals nerve-dependent and independent roles on mammalian hind limb tissue maintenance and regeneration

The requirement and influence of the peripheral nervous system on tissue replacement in mammalian appendages remain largely undefined. To explore this question, we have performed genetic lineage tracing and clonal analysis of individual cells of mouse hind limb tissues devoid of nerve supply during regeneration of the digit tip, normal maintenance, and cutaneous wound healing. We show that cellular turnover, replacement, and cellular differentiation from presumed tissue stem/progenitor cells within hind limb tissues remain largely intact independent of nerve and nerve-derived factors. However, regenerated digit tips in the absence of nerves displayed patterning defects in bone and nail matrix. These nerve-dependent phenotypes mimic clinical observations of patients with nerve damage resulting from spinal cord injury and are of significant interest for translational medicine aimed at understanding the effects of nerves on etiologies of human injury.

The Impact of Autonomic Dysreflexia on Blood Flow and Skin Response in Individuals with Spinal Cord Injury

Autonomic dysreflexia (AD) is an inappropriate response of the sympathetic nervous system that commonly occurs when individuals with spinal cord injury (SCI), at or above the sixth thoracic (T6) vertebra, are subjected to a noxious stimulus below the level of injury. An AD event can be put into motion by something as simple as an ingrown toenail or a full bladder, with symptoms ranging from headache, high blood pressure, and even stroke. We have characterized the onset of AD and resulting autonomic events in an individual with SCI using a fiberoptic-based probe. Two probes were located above and below the injury level, on the subjects forearm and thigh, respectively, and were connected to a dual channel spectrophotometer. Oxygen saturation was calculated using the reflectance spectra and an algorithm based on melanin and hemoglobin absorption. We noticed that during an AD event the amount of oxygen in the skin below the injury level dropped by as much as 40%, while above the injury level, skin oxygenation remained constant. In addition, we found that the level of skin perspiration below the level of injury increased significantly. We hypothesize that the combination of AD-related ischemia with pressure-related ischemia and increased perspiration places individuals with spinal cord injury level at T6 or above at an elevated risk for developing a pressure sore below the injury site.

Dermatological findings following acute traumatic spinal cord injury

STUDY DESIGN

Prospective study.

OBJECTIVE

To identify and define dermatological conditions following acute traumatic spinal cord injury (ATSCI) during inpatient rehabilitation.

SETTING

Spinal Cord Injury Unit, The Department of Neurological Rehabilitation, The Chaim Sheba Medical Center, Israel.

METHODS

During a 1-year study, all patients following ATSCI were prospectively studied for new dermatological findings during their inpatient rehabilitation. Every new dermatological finding was defined concerning its location with regard to the patient's neurological level, the time from injury to appearance and the exact dermatological diagnosis.

RESULTS

During the study year, 46 ATSCI patients were hospitalized in our department, of whom were 38 (82.6%) males and eight (17.4%) females (mean age 30.2 years). A total of 21 (45.6%) patients were tetraplegic and 25 (54.3%) paraplegic. Of the patients, 28 (60.9%) had complete neurological injuries and 18 (39.1%) incomplete. In all, 14 (30.4%) patients developed a dermatological condition. There was no significant age or sex correlation to the development of these complications. There was a greater likelihood of paraplegia (48 versus 9.5%, P=0.005) and being neurologically complete (42.9 versus 11.1%, P=0.02). The dermatological findings appeared on an average of 80.3 days after the initial neurological insult. There were a total of 22 different dermatological findings: 11 (50%) were local fungal infections, two (9.1%) psoriatic lesions, two (9.1%) hyperkeratotic lesions, two (9.1%) bacterial infections (one folliculitis, one impetigo) and single cases of seborrheic dermatitis, acne, alopecia, scabies and allergic reaction. Of the findings, 14 (63.6%) were below the neurological level, including all of the fungal infections.

CONCLUSIONS

Dermatological findings are common during rehabilitation of ATSCI. The clinical impact of these findings is low, but nevertheless, they are troublesome to the patient. The most common dermatological disorder was a local fungal infection below the neurological level. Paraplegic patients are more susceptible to the development of this condition. Patient and staff education regarding proper skin care may reduce these infections.

Use of behavioral contingencies to promote prevention of recurrent pressure ulcers

OBJECTIVE

To determine effectiveness of an intervention using monetary rewards as a consequence for preventing or reducing severity of pressure ulcers in spinal cord injury (SCI) patients with a history of chronic, recurrent ulcers.

DESIGN

Multiple baseline analysis across subjects (time-lagged control), comparing severity of pressure ulcers and treatment costs during baseline and intervention.

SETTING

Outpatient wound-care clinic of private, nonprofit specialty hospital.

PARTICIPANTS

Nine adults (all with paraplegia) with a history of hospitalizations for treatment of pressure ulcers.

INTERVENTIONS

In study 1, participants (n=6) undertook (1) a comprehensive self-care plan, (2) had a graduated schedule of visits with an advanced practice nurse, and (3) received monetary rewards for successfully preventing serious ulcers. In study 2, participants (n=3) undertook interventions 1 and 2, but monetary rewards were in staged phases so a component analysis could compare the effectiveness of visits alone to visits plus monetary rewards.

MAIN OUTCOME MEASURES

Severity of pressure ulcers measured with the Pressure Ulcer Scale for Healing (PUSH Tool 3.0); and direct costs of treatment and preventive care for pressure ulcers.

RESULTS

In study 1, severity of pressure ulcers-and their related treatment costs-decreased for the 6 participants. Maintenance of effects postintervention was highly variable, with only 3 participants showing long-term improvements. In study 2, for 2 participants, visits alone did not reduce pressure ulcer severity, but visits plus payments did effectively reduce ulcer severity, indicating improved prevention behaviors.

CONCLUSIONS

Findings support the assumption that pressure ulcers may recur among some individuals because there are insufficient positive consequences for effective prevention.

Localised necrosis of scrotum (Fournier's gangrene) in a spinal cord injury patient - a case report

BACKGROUND

Men with spinal cord injury (SCI) appear to have a greater incidence of bacterial colonisation of genital skin as compared to neurologically normal controls. We report a male patient with paraplegia who developed rapidly progressive infection of scrotal skin, which resulted in localised necrosis of scrotum (Fournier's gangrene).

CASE PRESENTATION

This male patient developed paraplegia at T-8 level 21 years ago at the age of fifteen years. He has been managing his bladder by wearing a penile sheath. He noticed redness and swelling on the right side of the scrotum, which rapidly progressed to become a black patch. A wound swab yielded growth of methicillin-resistant Staphylococcus aureus (MRSA). Necrotic tissue was excised. Culture of excised tissue grew MRSA. A follow-up wound swab yielded growth of MRSA and mixed anaerobes. The wound was treated with regular application of povidone-iodine spray. He made good progress, with the wound healing gradually.

CONCLUSION

It is likely that the presence of a condom catheter, increased skin moisture in the scrotum due to urine leakage, compromised personal hygiene, a neurogenic bowel and subtle dysfunction of the immune system contributed to colonisation, and then rapidly progressive infection in this patient. We believe that spinal cord injury patients and their carers should be made aware of possible increased susceptibility of SCI patients to opportunistic infections of the skin. Increased awareness will facilitate prompt recourse to medical advice, when early signs of infection are present.

Spinal cord injury rehabilitation. 2. Medical complications

This self-directed learning module highlights new advances in understanding medical complications of spinal cord injury through the lifespan. It is part of the chapter on spinal cord injury rehabilitation in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. This article covers reasons for transferring patients to specialized spinal cord injury centers once they have been stabilized, and the management of common medical problems, including fever, autonomic dysreflexia, urinary tract infection, acute and chronic abdominal complications, deep vein thrombosis, pulmonary complications, and heterotopic ossification. Formulation of an educational program for prevention of late complications is also discussed, including late renal complications, syringomyelia, myelomalacia, burns, pathologic fractures, pressure ulcers, and cardiovascular disease. New advances covered in this section include new information on old problems, and a discussion of exercise tolerance in persons with tetraplegia, the pathophysiology of late neurologic deterioration after spinal cord injury, and a view of the care of these patients across the lifespan.